Supreme Court says ER doctors can still do our jobs, at least for now.
Your "Five on Friday" lead story for June 28, 2024...
We are back with “Five on Friday", the feature where Inside Medicine behaves like an actual medical/health/science newsletter. Also, please vote in the poll at the end!
If you value this feature—and Inside Medicine in general…
Here we go…
Item 1: Emergency abortions still allowed in Idaho, EMTALA upheld.
The Supreme Court decided not to decide a case that pitted Idaho’s draconian abortion ban against the federal law (EMTALA) that requires emergency care clinicians to treat all comers, and attempt to save their lives, organs, or limbs. In doing so, the Supreme Court punted to a later time. However, the polarity of the situation means that a lower court’s halt on the law stands. As it stands, ER and other doctors can perform an abortion in emergencies to immediately save the life of the mother, and for other circumstances that could become deadly. The question in places where exceptions to abortion bans exist to save the life of the mother is where that line is for a number of situations. Who knows? There are simply too many variables. When a patient comes in who might die—or lose an organ, important bodily function, or a limb—unless we intervene soon, I don’t want to be thinking about whether the case is on the border of some ill-considered law. I just want to help them. While the Supreme Court’s action yesterday keeps the status quo in place for me and my colleagues nationwide, it’s troubling that the case was decided not on the merits, but on an apparent loss of appetite by the Justices for settling the issue.
Item 2: Blockbuster weight loss drug reduces obstructive sleep apnea.
In another major win for GLP-1 drugs (like Ozempic and Wegovy), a randomized clinical trial published in the New England Journal of Medicine found that tirzepatide (“Mounjaro”) substantially reduced dangerous events seen among obstructive sleep apnea (OSA) patients a year later. Patients with OSA frequently stop breathing (or close to it) for many seconds at a time while they sleep. Eventually, this causes heart problems, leading to heart failure and death. Many (though not all) OSA patients have obesity. The theory here was that for many of them, weight loss might help reduce the number of dangerous events. It did—with around 24-25 fewer dangerous events per hour in the treatment group, compared to placebo recipients. The findings were true both for patients who use “CPAP” machines at night and those who do not. While the study did not measure the long-term clinical outcomes of the study participants, it’s hoped that the improvements will lead to fewer hospitalizations and deaths down the road.
Item 3: Bullet-related injuries. A new framework.
Recently, I interviewed Dr. LJ Punch, who runs the Bullet-Related Injuries Clinic in St. Louis. Dr. Punch did something unusual which was to immediately change my perspective on a topic. For example, there’s a long-established dogma that says not to remove bullets from people who have been shot if the bullet is not threatening an important internal structure. Dr. Punch challenged me on this, asking why anyone ever thought this? The answers were illuminating, and they go back centuries. This was a fascinating conversation, and I hope you’ll view all three parts.
Part 1: A New Framework for Addressing 'Bullet-Related Injury'. LJ Punch, MD, on a bullet's physical, emotional, social, and spiritual impact.
Part 2: Treating the Trauma of Bullet-Related Injuries. "Retained bullets are one of the most malignant forms," of bullet-related injury, says Dr. LJ Punch.
Part 3: Bullet-Related Injuries: 'The Problem Is Our Relationship to Lethal Force'. Injuries will make one person cling to guns and another renounce them, says LJ Punch, MD.
Item 4: FDA widens approval for Muscular Dystrophy drug, despite negative data.
Last year, the FDA approved Elevidys, a gene therapy drug for Duchenne Muscular Dystrophy for use in children with the disease who have a certain gene variant. The decision was controversial at the time because of weak data, which showed a lack of efficacy. Then, in October 2023, an anticipated clinical trial further studying the treatment again failed. So, it’s fairly confusing that last week the FDA’s Director for the Center for Biologics Evaluation and Research overruled its own voting committee and decided to expand FDA approval to include all people with the disease, regardless of age, (again, provided they have the apparently relevant gene the therapy attempts to target). The decision was based on glimmers of hope seen in “secondary outcomes”—that is, a group of results that studies were not designed to study rigorously, and which, when positive, can form the basis of future high-quality studies.
Honestly, this not a great precedent. If studies can’t prove that drugs work as intended, researchers should need to do more work to prove that FDA approval is warranted. And when that work fails, regulators should respond accordingly and reject the applications. Otherwise, what is the point of science?
Item 5: Poll of the Week.
Here are the results from last week’s poll. Thanks for your votes! Seems like there’s interest. I’ll see what I can make happen!
Item 5a: Poll of the Week for this week!
We’ve discussed some areas of AI in healthcare here at Inside Medicine. Given what you know right now…
With a fairly broad question like this one, I especially welcome your insights in the Comments section! Thanks Inside Medicine community!
That’s it. Your “Friday Five!”
Feedback! Do you like the “Five on Friday” format? Have any ideas for next week’s Poll of the Week? Any great articles you read elsewhere that you want to share with the Inside Medicine community? Other musings or thoughts?
Please contribute to the Comments!
Regarding the poll, I felt undecided was the only correct answer right now since AI has the potential to do both great good and great harm. But I think the issue won't be only or even mainly technical: it will be who uses it for what motivations. Will it mainly be used by bean counters to deny human care? Will it mainly be used by the well-intentioned but unrealistic dreamers who disregard unintended consequences? Or will it be used by those with both a moral compass and the understanding that EVERY major new technology has unintended effects?
Of course all these sorts of people will use AI. But whose uses will have the greatest impact? That is the question to which I don't know the answers.
I was in the hospital this week for an Eliquis related brain bleed. The human touch aspect of my care was especially important to the odd and frightening sense of isolation that such a stay evokes. I worry AI will be used to reduce staff in a way that limits human interaction even more. No!!! That would be so deleterious to healing. So I’m undecided about its use. I do love that it will make charting easier. But there’s no place for it in situations where a person is key. My neurologist was charting close by when I woke from my burr hole procedure. He came over took my hand and said “Welcome back.” There’s no replacement for that!